Senate debates Tuesday, 4 March 2014

Aviation Transport Safety Bureau

I would like to speak tonight on an incredibly seriously issue that goes to the heart of aviation safety in Australia. In May last year, the Senate Rural And Regional Affairs and Transport References Committee handed down a damning report into the Aviation Transport Safety Bureau’s investigation of Pel-Air flight VH–NGA off Norfolk Island in 2009. At the outset, I want to acknowledge the excellent work of the committee secretariat in this inquiry. I also want to acknowledge the contribution of Senator David Fawcett—that is you, Mr Acting Deputy President—whose experience and expert knowledge were invaluable to the other committee members.

I am very grateful for that, as are the rest of the committee.

I also want to thank the individuals involved in the incident, and their advocates and representatives, for the time and effort they spent to ensure the committee fully understood the events of that night and their implications. Bryan Aherne and Mick Quinn, experts in aviation safety with distinguished careers in aviation, deserve recognition. Mr Quinn is a former deputy director of CASA. Mr Aherne is an independent safety expert who is also very highly regarded.

The inquiry report notes that the committee had strong concerns about the methodology the ATSB used to attribute risk:

The methodology appears to defy common sense by not asking whether the many issues that were presented to the committee in evidence, but not included in the report, or not included in any detail, could:

That is indicative of the abject failures of the ATSB in investigating that accident. It was also incredibly distressing to hear, during the committee process, of the physical and emotional impact on these individuals—and I hope that they will be fully vindicated soon.

The Senate inquiry was not an attempt to reinvestigate the circumstances of the ditching. Instead, it focused on the ATSB investigative process and how that process was reflected in the ATSB’s findings regarding VH-NGA.

The Senate committee’s report sets out how the pilot of the Pel-Air flight on that fateful night was, in my view, made a scapegoat by the ATSB. What the committee discovered was that the ATSB appeared to give little consideration to systemic failures and instead laid most of the blame at the feet of the pilot, Dominic James.

A key feature of world’s best practice accident investigation is to look not at the actions of individuals but at the environment in which those actions took place—something that you well know, Mr Acting Deputy President, with your distinguished career as a test pilot.

By doing so, investigators can establish the flaws in the system so that they are not repeated. Instead, what the Senate committee discovered was that, while the ATSB was aware of systemic failures—poor fatigue management and flight-planning systems on the part of the operator Pel-Air—they largely ignored these in favour of focusing on the actions of the pilot, Dominic James.

I spent a lot of time with Mr James before and during the inquiry, and he is the first one to tell you that, yes, he made some mistakes that night. But would he have made those same mistakes if the company he was working for had insisted on proper rest for its pilots and ensured that they had appropriate tools for flight planning?

Common sense says no, he would not. But the ATSB seems to differ. What is even more concerning is that a document came to light during the inquiry that revealed CASA were aware of significant regulatory breaches within Pel-Air and also their own failures to enforce those regulations. Despite a memorandum of understanding with the ATSB that required CASA to share this information, they did not do so.

The committee’s recommendations cover a significant number of issues, among them the ATSB’s investigative processes; the classification and regulatory oversight of aeromedical flights; the provision of weather information; and the application of the MOU between the ATSB and CASA.

The committee also raised concerns about the ATSB’s decision not to retrieve flight data recorders from the ditched plane despite the ATSB’s responsibilities under the International Civil Aviation Organization’s annexe 13 ruling. The committee was so concerned with Mr Dolan’s comments on this front that it stated in its report:

Mr Dolan’s evidence in this regard is questionable and has seriously eroded his standing as a witness before the committee.

This is an incredibly strong statement in regard to a senior public servant. I do not understand how Mr Dolan’s position in the ATSB is tenable. And yet, neither the previous government nor the current government has formally responded to the committee’s report—but I understand it is coming shortly.

The ATSB’s response to this report has been to commission Canada’s Transport Safety Board to undertake a review of the ATSB’s investigative processes, with particular reference to the Pel-Air investigation and two other incidents.

However, it emerged in Senate estimates just last week that the Canadian TSB have only reviewed the investigation on the documents. They have not interviewed the individuals involved in the incident and those individuals who provided extensive evidence, such as Mr Quinn and Mr Aherne, even though those individuals are very critical of the ATSB’s processes.

As I understand it, they have not spoken to members of the Senate committee or even to CASA.

Given the many issues regarding oversight and transparency that were raised in the committee report, this is incredibly concerning. It is hard to understand how the Canadian TSB can produce a useful or meaningful view without digging further than the surface documents. This should not be a tick and flick exercise.

The people involved in this incident—the pilot, Dominic James; the co-pilot; the patient and her husband on the aeromedical flight, Mr and Mrs Currall; the doctor; and the nurse, Karen Casey—have had their lives permanently affected.

Their suffering has been significant—in particular, Ms Casey, who cannot go back to her work as a nurse. They all deserve better. The Canadian TSB needs to be given carte blanche to examine papers, to interview witnesses and interested parties, and to release its report to the public. The fact that it has not done so to date concerns me greatly.

There has been more than enough pushed under the carpet in this case. My fear is that the Canadian TSB may unwittingly be involved in what could end up being a whitewash on behalf of the ATSB.

It is time to accept the mistakes that have been made, because without accepting those mistakes we cannot learn; and, if we cannot learn, then we cannot change, and that would be a tragedy in every sense of the word.

No lives were lost in the Pel-Air incident due to the great skill of the pilot and some good luck.

But unless these systemic issues—a

lack of transparency,

lack of regulatory oversight,

desire to protect instead of expose—

are addressed we cannot guarantee that no lives will be lost in the future, and that would be the greatest tragedy of all.